Healthcare Provider Details

I. General information

NPI: 1861801367
Provider Name (Legal Business Name): ABDUL WASI I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 01/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6451 SCHAEFER RD
DEARBORN MI
48126-2212
US

IV. Provider business mailing address

19445 W WARREN AVE
DETROIT MI
48228-3361
US

V. Phone/Fax

Practice location:
  • Phone: 313-945-8138
  • Fax: 313-624-9418
Mailing address:
  • Phone: 734-262-4386
  • Fax: 734-661-4501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301010716
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802069405
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: